Preventing medication errors in transitions of care: A patient case approach

To discuss common causes of medication errors occurring upon transitions of care and review key interventions that should be implemented to ensure effective communication and accurate completion of medication reconciliation.

MEDLINE (1946 to November 2014) using MeSH terms medication errors, medication reconciliation, and nursing homes in addition to conventional text words, including transitions of care and medication safety; Agency for Healthcare Research and Quality Patient Safety Network using search terms transitions of care, medication errors, and medication reconciliation; and relevant websites of national organizations pertaining to transitions of care and medication reconciliation.

Limited to English-language journals with no limitation set on the year of publication for clinical trials, meta-analyses, and reviews.

At the authors' discretion, preference was given to references focusing on pharmacists' role in transitions of care and medication reconciliation.

Most medication errors stem from a lack of effective communication between health care providers during transitions of care. Part of successful communication and correct patient hand-off is completing accurate medication reconciliation. A patient case highlights a life-threatening medication error that occurred during a transition of care due to ineffective communication between a pharmacist and nurse while transferring medication information.

To provide patients with accurate medication information, pharmacists should perform medication reconciliation upon transitions of care using The Joint Commission's five-step process. Pharmacists can conduct numerous interventions to prevent medication errors during transitions of care and ensure patient safety. Pharmacists are integral to evaluating the appropriateness of medication use, ensuring information is updated in the health record, and verbally communicating accurate information to other health professionals.